MEDICARE: RUSSELL B KIMBALL PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA590	ME

General Provider Information

NPI Number	:	1841380235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL B KIMBALL PA-C

Provider Business Mailing Address
First Line	:	31 JOHNSON STREET
Second Line	:
City	:	SOUTH GARDINER
State	:	ME
Zip	:	04359
Country	:	US
Telephone Number	:	207-512-2318
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 ARSENAL ST
Second Line	:
City	:	AUGUSTA
State	:	ME
Zip	:	04333-0011
Country	:	US
Telephone Number	:	207-624-4657
Fax Number	:	207-287-6123

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	07/08/2007

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